﻿<%@ Page Title="" Language="C#" MasterPageFile="~/Admin.Master" AutoEventWireup="true" CodeBehind="MemberInfo.aspx.cs" Inherits="NewGlobalBizAssist.MemberInfo" %>
<asp:Content ID="Content1" ContentPlaceHolderID="HeadContent" runat="server">
  <script type=text/javascript>
      $(function () {
          $("#datepicker").datepicker({
              changeMonth: true,
              changeYear: true
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          $("#MainContent_dtregister").datepicker({
	            changeMonth: true,
	            changeYear: true
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	        $("#MainContent_dtstart").datepicker({
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	            changeYear: true
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	        $("#MainContent_dtend").datepicker({
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	        $("#MainContent_dtbday").datepicker({
	            changeMonth: true,
	            changeYear: true
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	</script>
</asp:Content>
<asp:Content ID="Content2" ContentPlaceHolderID="MainContent" runat="server">

 
              <table class="textb">
              <tr>
                    <td bgcolor="#999999"><strong>Member Plan</strong></td>
                    <td colspan="2" bgcolor="#999999"><select name="txt_memberplan" id="txt_memberplan">
                      <option value="M-350" selected>M-350</option>
                      <option value="M-500" >M-500</option>
                      <option value="M-800" >M-800</option>
                      <option value="M-1200" >M-1200</option>
                      <option value="M-1500" >M-1500</option>
                      <option value="M-1800" >M-1800</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Member Category</strong></td>
                    <td colspan="2" bgcolor="#999999"><select name="txt_membercategory" id="txt_membercategory">
                      <option value="Agent" >Agent</option>
                      <option value="Client" selected>Client</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Agent Plan</strong></td>
                    <td colspan="2" bgcolor="#999999"><select name="txt_agentplan" id="txt_agentplan">
	                  <option value="" selected>N/A</option>
                      <option value="F-999" >F-999</option>
                      <option value="U-499" >U-499</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Member Position</strong></td>
                    <td colspan="2" bgcolor="#999999"><select name="txt_memberposition" id="txt_memberposition">
                      <option value="Agent" selected>Agent</option>
                      <option value="BC" >BC</option>
                      <option value="BDO" >BDO</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Approval #</strong></td>
                    <td colspan="2" bgcolor="#999999"><input name="txt_membernum" type="text" id="txt_membernum" value="64203158" size="50%" maxlength="25"></td>
                  </tr>
                  <tr>
                    <td width="26%" bgcolor="#999999"><strong>Member ID</strong></td>
                    <td colspan="2" bgcolor="#999999"><input name="txt_memberid" type="text" id="txt_memberid" value=""   maxlength="25" runat="server"></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Member Name</strong></td>
                    <td colspan="2" bgcolor="#999999"><input name="txt_membername" type="text" id="txt_membername" value="" maxlength="100" runat="server"></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Agent</strong></td>
                    <td colspan="2" bgcolor="#999999"><strong>
                      <input name="txt_memberagent" type="text" id="txt_memberagent" value="M2ML000072"  maxlength="25">
                    </strong></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Business Center</strong></td>
                    <td colspan="2" bgcolor="#999999"><strong>
                      <input name="txt_memberbc" type="text" id="txt_sponsor3" value="M2ML000072"  maxlength="25">
                    </strong></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Regional Manager</strong></td>
                    <td colspan="2" bgcolor="#999999"><strong>
                      <input name="txt_memberrm" type="text" id="txt_sponsor4" value="HO"  maxlength="25">
                    </strong></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999"><strong>Date Registered</strong></td>
                    <td colspan="2" bgcolor="#999999"> <input type="text" id="dtregister" runat="server"/></td>
                  </tr>
                  <tr>
                    <td bgcolor="#999999">&nbsp;</td>
                    <td colspan="2" bgcolor="#999999">&nbsp;</td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Age</span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="txt_age" type="text" id="txt_age" value="" size="5" maxlength="3">
                      (Optional) </span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Birthdate</span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb"><input type="text" id="dtbday" runat="server"/>(Optional) </span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Birthplace </span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="txt_birthplace" type="text" id="txt_birthplace" value="" size="50%" maxlength="100">
                      (Optional) </span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Gender</span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="gender" type="radio" value="Male" checked>
                      Male
                      <input name="gender" type="radio" value="Female" >
                      Female</span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Status </span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="mstatus" type="radio" value="Single" checked>
                      Single
                      <input name="mstatus" type="radio" value="Married" >
                      Married
                      <input name="mstatus" type="radio" value="Widow" >
                      Widow
                      <input name="mstatus" type="radio" value="Separated" >
                      Separated</span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Home Address</span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="txt_address" type="text" id="txt_address" value="" size="50%" maxlength="200">
                      (Optional) </span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Tel. # </span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="txt_telno" type="text" id="txt_telno" value="" size="50%" maxlength="15">
                      (Optional) </span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Mobile # </span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="txt_mobileno" type="text" id="txt_mobileno" value="" size="50%" maxlength="15">
                      (Optional) </span></td>
                  </tr>
                  <tr>
                    <td bgcolor="#CCCCCC"><span class="textb">Email Address</span></td>
                    <td colspan="2" bgcolor="#CCCCCC"><span class="textb">
                      <input name="txt_email" type="text" id="txt_email" value="" size="50%" maxlength="100">
                      (Optional) </span></td>
                  </tr>
                  <tr>
                    <td height="40" bgcolor="#FFFFCC"><strong><span class="titleb">APPROVAL LETTER</span></strong></td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb">&nbsp;</td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">Date Coverage</td>
                    <td width="16%" bgcolor="#FFFFCC" class="textb">Starting Date</td>
                    <td width="58%" bgcolor="#FFFFCC" class="textb"><input type="text" id="dtstart" runat="server"/></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">&nbsp;</td>
                    <td bgcolor="#FFFFCC" class="textb">End Date</td>
                    <td bgcolor="#FFFFCC" class="textb"><input type="text" id="dtend" runat="server"/></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">Enrollment Number</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><input name="txt_enrollnum" type="text" id="txt_enrollnum" value="64203158" size="50%" maxlength="25"></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">Memorial Service</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><input name="txt_memorialservice" type="text" id="txt_memorialservice" value="M-350" size="50%" maxlength="100"></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">Service Value</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><select name="txt_atneedprice" id="txt_atneedprice">
                      <option value="15000" selected>15,000.00</option>
                      <option value="20000" >20,000.00</option>
                      <option value="35000" >35,000.00</option>
                      <option value="50000" >50,000.00</option>
                      <option value="75000" >75,000.00</option>
                      <option value="100000" >100,000.00</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">Servicing Mortuary</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><input name="txt_servicemortuary" type="text" id="txt_servicemortuary" value="OPEN" size="50%" maxlength="100"></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">MSA Hotline</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><input name="txt_msahotline" type="text" id="txt_msahotline" value="(02)250-1026" size="50%" maxlength="100"></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">Cash Assistance</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><select name="txt_cashassistance" id="txt_cashassistance">
                      <option value="" >N/A</option>
                      <option value="5000" selected>5,000.00</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td bgcolor="#FFFFCC" class="textb">Accidental Death Benefit</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><select name="txt_accidentalbenefit" id="txt_accidentalbenefit">
                      <option value="10000" selected>10,000.00</option>
                      <option value="50000" >50,000.00</option>
                      <option value="75000" >75,000.00</option>
                      <option value="100000" >100,000.00</option>
                    </select></td>
                  </tr>
                  <tr>
                    <td valign="top" bgcolor="#FFFFCC" class="textb">Remarks</td>
                    <td colspan="2" bgcolor="#FFFFCC" class="textb"><textarea name="txt_remarks" cols="50%" rows="5" id="txt_remarks">1st year enrollment under 6-month contestability period.</textarea></td>
                  </tr>
              </table>
</asp:Content>
